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...... .. . . ......... ........ APPLICATION FOR SANITATION PERMIT SQL _ 70`45ZV-710-A ZZ <br /> ..................................... {Complete in Triplicate) Permit NQ17-r ---... - <br /> This Permit Expires 1 Year From Date issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> described, This application Is Ir core 110 With Count Ordinance permit to construct and Install the work herein <br /> 67 25 � and existing Rules and Regulations, <br /> JOB ADDRESS/LOC <br /> r`•--/ - <br /> ENSUS TRACT ...-......-- <br /> Owner's Name .".. - '• - ""�•••--• <br /> .. ............... <br /> Address .- ---•-- ------ .................... ne .�� . .-. <br /> -- Ci <br /> Contractor's Name ---------- --- • `�" - . .......-............................. <br /> __..._••---......_..... <br /> - -- -------- <br /> -- license # _ <br /> Installation will serve: Res encs❑Apartment House❑ Commercia Tralter Court Phon .� �� <br /> Motel ❑Other----------- A ❑ <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ._-.___•-----_---........Supply: Public System and name --------------- -•••••• -•-•••-------••--- <br /> Character of soil to a depth of 3 feet: Sand Private❑ <br /> ❑ Silt❑ Clay 0 Peat❑ Sandy Loam ❑ Clay Loam p <br /> Hardpan ❑ Adobe 0 Fill Material ............ If yes, <br /> (Plot plan, showing size of lot, location of system in relation to wells, <br /> NEW INSTALLATION: buildings, etc, must be plated on reverse side,) <br /> INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK <br /> Size---•------•-•-•-•••------------- ------•----•- LiquidDepth ._....._..- <br /> ---•---•-••----Capacity •------------------- Type ---------------•-• � <br /> Material.-..••--•--•• <br /> -•--•--- No. Compartments ' <br /> Distance to nearest: Well --.-•----•--- ----•--------•---.._.. <br /> LEACHING LINE •-------•---------•----Foundation ------------_- Prop. Line ----------•--- -•--•• 0_ <br /> No <br /> [ ) . of Lines ........................ Length of each line---•------,"--_••-••-------• Total Length 4 <br /> 'D' Box ------------ Type Filter Material ......... Depth Filter Material terial S <br /> ..-...-. <br /> ...A <br /> Distance to nearest: Well ---------- -•--•------• <br /> ----------•--_ Foundation <br /> SEEPAGE PIT ........................ Property Line <br /> � Depth .............. . .....Z <br /> --."---------------- Diameter -..---. -.". <br /> Number ---------------- Rock Filled Yea ❑ No �[] <br /> Water Table Depth ............................ ..............Rock Size --...--..- <br /> istance to nearest: Well -----------------•--•--•------__•-------Foundation _------------• t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .............•--------------------------- Prop. line ----------------•---- <br /> --- Date .--------•-------------- <br /> Septic Tank (Specify Requirements) ............... <br /> .---.....-. <br /> _--_-• !-�•- <br /> ,. - <br /> --.....Disposal Field IS ,cifY Requirements) _ <br /> ----------------------------------•-------•---------- ---_---_---------------_------- --- -- - <br /> (Draw existing and required addition on reverse side) " <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Jopquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin local Health District. Home owner a Hton- <br /> sed agents signature certifies the follo <br /> "I certify that in erformance of the rl permit is .Issued I shall not employ an <br /> as to beco s ject o km iP y ]► person in such manner <br /> Signed ---- $a o fifornla." <br /> --- •- <br /> - ---• Owner <br /> BY --------- •---•-- -�-- <br /> "- •-----•-------•----------------------------------------- Title -- ---- <br /> (If other than owner) -- -" <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ,.- <br /> BUILDING PERMIT ISSUED - � s <br /> ..----"------- ------- ------•---. DATE . " ...�.� .- -- <br /> - <br /> ADDITIONAL COMMENTS "------- -DATE - --------•--- -- <br /> ------------•-------- ".._- <br /> -.-- <br /> Final Inspection by: .--..---- - •- -. -/--•,---- <br /> -------------- <br /> EH 13 24 1--68 He;,. 5M ---------••-------------- ..................... -------- ---------.—Date . ���--- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7L 3M <br />